LAC+USC Medical Center
The Division of PCCSM operates the Medical Intensive Care Unit services at LAC+USC. In addition, the Division provides consultative services to inpatients and to intensive care units of other divisions and departments, including internal medicine, surgery (including trauma), neurology, neurosurgery, burns, emergency medicine and cardiology. The Division conducts a weekly Chest Continuity Clinic, at which residents and fellows evaluate new patients and provide continued care for established patients. The Procedural Service at LAC+USC performs more than 700 bronchoscopic examinations annually, as well as advanced procedures such as percutaneous tracheostomy, bronchial thermoplasty, endobronchial ultrasound (EBUS) and electromagnetic navigational bronchoscopy. The Pulmonary Physiology Laboratory and Sleep Center under the medical direction of the Division performs an average of 6500 lung function tests and 1184 sleep studies every year.
Keck Hospital of USC
The Division participates in the care of patients at four Intensive Care Units at KH, including the newly established Medical Intensive Care Unit, involving the care of inpatients with a wide spectrum of lung disease and critical illnesses. The PCCSM fellow performs all diagnostic and therapeutic procedures, including bronchoscopies, under the supervision of an attending physician. Specialized, multidisciplinary programs that provide patient-centered care include the Lung Transplant Program, Adult Cystic Fibrosis Center, Center for Advanced Lung Disease, Multidisciplinary Center for Lung Cancer Management, Asthma and Allergy Program, Sleep Center and Pulmonary Hypertension Program. The Center for Advanced Lung Disease sees patients with interstitial lung disease and airway diseases, including chronic obstructive pulmonary disease (COPD) and asthma, and recently established a bronchial thermoplasty program for treatment of patients with refractory asthma.
USC Norris Cancer Hospital
Norris provides an unparalleled opportunity to deliver care to a large number of patients with malignancy, immunosuppression and bone marrow transplantation. The Division of PCCSM runs the Intensive Care Unit at Norris Hospital and provides consultative services to floor patients. The PCCSM fellow carries out all consultations and performs diagnostic, invasive and noninvasive, and therapeutic procedures under the supervision of the attending staff. Lung cancer patients are seen at the Multidisciplinary Clinic and reviewed at the weekly thoracic tumor board.
Special Clinical Services
The Division of PCCSM has established several clinical programs of excellence, each of which offers specialized treatment of various pulmonary disorders, as well as an educational setting for fellowship training:
The USC Asthma and Allergy Center is a comprehensive clinical program for the diagnosis and management of patients with asthmatic and/or atopic disorders (such as allergic rhinitis and sinusitis), which affect more than 20 million people in this country. The Asthma and Allergy Center is staffed by full-time teaching faculty who are certified in pulmonary, allergic and immunologic diseases. Besides physician specialists, resources include clinical allergy nurse specialists, respiratory therapists, nutritionists and pharmacologists. A state-of-the-art pulmonary function laboratory has capabilities for airflow measurements, including methacholine challenge studies to detect hyperirritable airway disorders. State-of-the-art skin testing for common pollen allergens, animal dander, dust mites, common molds and common foods is available. Testing by the RAST method for hypersensitivity pulmonary disease, including allergic bronchopulmonary aspergillus, is also offered. Skin testing for hymenoptera hypersensitivity (bee venom) and penicillin allergy is also available. If warranted, immunotherapy (desensitization) can be initiated for selected patients. Other novel therapeutic interventions offered include biological therapy for selected asthma phenotypes such as omalizumab (Xolair®) and mepolizumab (Nucala®).
The Center participates in several U.S. multi-center clinical trials that include patients with asthma. An ongoing trial sponsored by the pharmaceutical industry is the use of librikizumab for patients with severe asthma.
Our Division was the first academic center in Southern California to successfully perform a bronchial thermoplasty (BT) procedure in 2013. The USC Bronchial Thermoplasty Program was subsequently launched, and we are one of the only national sites with a unique multi-disciplinary format. Our bronchial thermoplasty team is comprised of both allergists and pulmonologists, as well as trained respiratory therapists and a nurse coordinator. Each month, the group meets to formally discuss patients and obtain consensus opinion on whether or not they can undergo BT safely. Dr. Richard Barbers, Dr. Ching-Fei Chang and Dr. Ramyar Mahdavi comprise the interventional arm of this program. Between the KH and LAC+USC sites, we have performed over 67 of these complicated procedures to date, with excellent results. In addition to being officially designated a Center of Excellence for Bronchial Thermoplasty, USC is also a major BT training site for Boston Scientific. Thus far, we have hosted six successful physician preceptorships at our campus, including both out-of-state colleagues as well as international visitors from Brazil.
In the past year, the Division has also greatly expanded its interventional pulmonary capabilities. Previously, Dr. Ching-Fei Chang spearheaded the availability of advanced flexible bronchoscopy procedures (e.g. EBUS-TBNA, Electromagnetic Navigational Bronchoscopy, and Bronchial Thermoplasty) at both the KH and LAC+USC sites, and to date, over 500 EBUS, 150 EMN, and 67 BT procedures have been successfully performed. Not only are these cutting-edge outpatient procedures less invasive and more comfortable than traditional surgical options, but they offer comparable diagnostic yields at a fraction of the cost. Now, with the recruitment of Dr. Ramyar Mahdavi, a board certified, fellowship trained interventional pulmonologist from the University of Wisconsin, our division is able to offer interventions requiring rigid bronchoscopy—such as argon plasma ablation, laser debulking, balloon dilation and stenting– for the palliative treatment of endobronchial tumors as well as stent placement for benign pathologies like tracheobronchomalacia, lung transplant complications or management of tracheal and airway stenosis resulting from complications of prolonged intubation or other etiologies.
Other procedures that we offer include: percutaneous tracheostomy, medical thoracoscopy, and pleur-X catheter placement. Together, Dr. Chang and Dr. Mahdavi comprise the new USC Interventional Pulmonary Team, and they provide a full spectrum of services for the minimally-invasive diagnosis, staging, and management of lung cancer, as well as advanced cutting-edge interventions in the airways, parenchyma, and pleural space.
Under the direction of Dr. Ching-Fei Chang, our division was the first to organize, lead, and execute a two-day Regional Fellowship Critical Care Ultrasonography Training Workshop in the Southern California area. With the assistance of UCLA colleague, Dr. Igor Barjaktarevic, and nationally-renowned ultrasound expert, Dr. Pierre Kory, Dr. Chang and colleagues trained over 35 first year fellows from USC and neighboring institutions, including UCLA, Harbor-UCLA, Cedar-Sinai, and UC Irvine. The overwhelming success of this collaborative inter-fellowship program has led to the commitment of all involved to continue this introductory course on an annual basis at rotating sites.
The USC Sleep Disorders Center continued its double-digit growth rate in 2015. As a vital component of our “Center for Advanced Lung Disease,” sleep medicine continued its expansion, with outpatient visit volume up approximately 20% and outpatient sleep study volume up 9% in 2015. We also initiated a new program for out of center home sleep testing. Our two sleep specialists, Terese C. Hammond, MD and Raj Dasgupta, MD, saw 1184 new and follow up sleep patients last year, both individually and in conjunction with our two sleep fellows, David Kent, MD and Katherine Green, MD. Both of our 2014-2015 graduating sleep fellows, Kaveh Rezvan, DO and Emily Gillett, MD, PhD, successfully attained board certification in sleep medicine and we participated in the NRMP matching program to fill our two ACGME-accredited sleep fellowship slots for 2016-2017.
Fostering research collaborations remained a principle focus of the Sleep Disorders Center in 2015. Through our continued close collaboration with Eric Kezirian, MD, of the USC Caruso Department of Otolaryngology, we became the first center in Southern California to implant the Inspire hypoglossal nerve stimulation device, which received FDA approval in 2015 for the treatment of obstructive sleep apnea in patients resistant to CPAP therapy. We also concluded our enrollment for the multi-center Respircardia trial of its Remede transvenous phrenic nerve pacing device for treatment of central sleep apnea. We initiated a cross-discipline research collaboration with Michael Khoo and Krishna Nayak of the Viterbi School of Engineering to use advanced MRI techniques to phenotype the airways of adult patients with obstructive sleep apnea. This complements previous work done by Sally Ward, MD and other CHLA investigators who incorporated us into their ongoing work using dynamic MRI to characterize the airways of obese children with OSA. Additional research initiatives in 2015 included collaboration with Jason Kutch, PhD, to examine relationships between sleep architecture and pelvic floor muscle activation in patients with chronic pelvic pain and ongoing work with Tomas Konecny, MD, PhD, of the Division of Cardiovascular Medicine, to more closely examine the generation of atrial arrhythmias in patients with implantable recording devices and sleep disordered breathing.
Both Drs. Hammond and Dasgupta continued their community outreach work. Dr. Dasgupta had a number of guest appearances as the resident sleep expert on the syndicated television show “The Doctors” and was a featured guest on “Larry King Live” and ESPN. He was also appointed the National Director of Media Outreach and Education for the American Academy of Sleep Medicine (AASM). Dr. Hammond gave multiple community grand rounds presentations and was invited to serve as a keynote speaker for the “Trojan 50” 2016 “Back to College Day”, where she presented her vision of the future of sleep medicine and collaborative sleep research.
The USC Pulmonary Exercise Program provides outpatient exercise evaluations. Exercise studies are performed with state-of-the-art equipment by experienced exercise technologists. Individuals with suspected functional impairment during any type or grade of exercise would benefit from an exercise evaluation to identify the physiologic cause for impairment. Information obtained from the study can be used to tailor specific exercise regimens and therapeutic strategies. The program offers Standard Pulmonary Stress Tests, Oxygen Desaturation Studies, Exercise-Induced Bronchospasm Studies and Metabolic Studies. The Medical Director of Respiratory Services is Dr. David Kelley.
The High-Altitude Simulation Test (HAST) is a specialized type of oxygenation study available in our Pulmonary Function Laboratory at KH. This study is performed on individuals who have marginal oxygenation and are considering excursions into high altitudes, including flying in an airplane. The study objective is to determine the quantity of supplemental oxygen that is required for a safe trip at various altitudes, and it is performed at rest and with gradients of activity. The Medical Director is Dr. David Kelley.
The USC Pulmonary Rehabilitation Program based at LAC+USC offers a wide range of services to patients with chronic pulmonary disease, from single sessions focused upon a specific need (such as training in the use of metered dose inhalers) to a comprehensive program consisting of two afternoons per week for a total of six to eight weeks. The comprehensive program includes exercise training, patient education, psychosocial support services, physical therapy, vocational therapy, symptom control techniques and the use of low-flow oxygen. Patients typically referred to the program include those with emphysema and pulmonary fibrosis. The program also offers on-site educational opportunities for pulmonary fellows with emphasis on respiratory physiology, quality-of-life assessment and key aspects of evaluating physical impairment and disability. The Medical Director is Dr. Ahmet Baydur.
Our Division was instrumental in the launching of the USC Multidisciplinary Lung Cancer Program in 2012. The program includes several faculty members from PCCSM (Drs. Alex Balekian, Ching-Fei Chang and Ramyar Mahdavi) who actively participate in the evaluation, diagnosis and management of patients with thoracic cancers. In collaboration with two thoracic surgeons, Dr. Hagen and Dr. Oh, this program is nationally recognized by the Lung Cancer Alliance as a Center of Excellence for Lung Cancer Screening. Thus far, we have screened 232 patients for lung cancer with the discovery of three malignancies. Our multidisciplinary team format is especially unique; not only does our tumor board meet every Wednesday – complete with a dedicated thoracic radiologist, three pulmonologists, two medical oncologists, two radiation oncologists, two thoracic surgeons, and a nurse navigator – but every Friday, we hold a multidisciplinary lung cancer clinic staffed by pulmonologists and representatives from medical oncology, radiation oncology and thoracic surgery, at the Multidisciplinary Lung Cancer Clinic at Norris. This clinic is designed to streamline the coordinated assessment of patients with or suspected of having lung cancer. Each faculty member also has a separate private clinic in which they assist with evaluation and management of dyspnea and other respiratory complications which may arise during the course of oncologic treatment. The pulmonary faculty members also provide teaching and guidance in the management of lung cancer patients at the LAC+USC Pulmonary Clinic every Wednesday afternoon. We are also on the path to creating a new “air way program” which is a collaborative multi-specialty program including interventional pulmonary, otolaryngology and thoracic surgery.
The USC Center for Advanced Lung Disease is a newly established program that deals with the diagnosis and treatment of all types of complex lung diseases. In addition to cystic fibrosis and sleep breathing disorders, the Center for Advanced Lung Disease houses clinics specializing in COPD, sarcoidosis and interstitial lung diseases, including idiopathic pulmonary fibrosis (IPF), hypersensitivity pneumonitis, collagen vascular disease, eosinophilic granuloma, pulmonary eosinophilia and other rare lung diseases. The USC Center for Advanced Lung Disease has been designated as an Alpha-1 Foundation Clinical Resource Center and a LAM Foundation Core Clinic. The Medical Director of the Center is Dr. A. Purush Rao.
The USC Sarcoidosis and Interstitial Lung Disease Center is now housed under the USC Center for Advanced Lung Disease. The Center continues to deal with the diagnosis and treatment of all types of interstitial lung diseases including sarcoidosis, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, collagen vascular disease, eosinophilic granuloma and pulmonary eosinophilia. Over the last 40 years, and previously led by the late world-renowned expert Dr. Om Sharma, these services have been provided to patients from all over the world. Dr. Alex Balekian now sees patients with interstitial lung disease.
The USC Comprehensive Adult Cystic Fibrosis Center provides direct care and consultation for adult cystic fibrosis patients. The cystic fibrosis care team is headed by pulmonologists supported by a full range of consultants, including endocrinologists, gastroenterologists, otolaryngologists, infectious diseases experts, general surgeons and cardiothoracic surgeons. Allied health services are provided by pulmonary clinical nurse specialists, dieticians, clinical social workers, physical therapists, occupational therapists and respiratory therapists. State-of-the-art therapies are offered, and there are gateways to research protocols and lung transplantation. Dr. A. Purush Rao serves as Medical Director.
Lung transplantation is a treatment option for many patients with end-stage pulmonary disease. The USC Lung Transplant Program at Keck Medical Center of USC is comprised of experts in cardiothoracic surgery, pulmonary medicine, cardiology, immunology, infectious disease, critical care medicine, cystic fibrosis, perfusion medicine, immunosuppression pharmacology, occupational and physical rehabilitation, and social/psychological services. Patients eligible for lung transplantation include those severely debilitated by cardiopulmonary disease and not hampered by other organ system dysfunction. Candidates frequently have the diagnosis of obstructive lung disease (e.g., emphysema, cystic fibrosis, bronchiectasis), pulmonary hypertension (both primary and secondary) or pulmonary fibrosis (e.g; IPF, hypersensitivity pneumonitis, sarcoidosis, LAM).
Patient education and communication are essential to improve the awareness to lung transplant referral and long term outcome. We have created Lung Transplant support groups to help our patients cope with their illnesses and learn more about their diagnoses. The Lung Transplant program is under the direction of Sivagini Ganesh, MD.
The Pulmonary Hypertension Program offers a comprehensive and multidisciplinary approach to patients with this rare and very serious disorder of the blood vessels of the lung. Patients with pulmonary hypertension are frequently not recognized until they have advanced disease because early symptoms can lead to misdiagnosis. A higher awareness, earlier diagnosis and development of a comprehensive treatment plan can dramatically improve quality of life and prognosis for patients with this life-threatening condition. Many therapeutic modalities are highly complex and require intensive patient education and ongoing follow-up with subspecialty physicians and nurse specialists. Medical services such as continuous prostaglandin therapy, oral vasodilator therapy, anticoagulation therapy and home oxygen therapy are provided and coordinated by a multidisciplinary team. When appropriate, referrals are made for lung transplant, heart lung transplant as well as ECMO as a bridge to transplant.
Pulmonary hypertension research is rapidly growing, and patient education and communication are essential to support that growth. We have created pulmonary hypertension support groups to help our patients cope with their illness and learn more about their diagnoses. Patients with pulmonary hypertension are evaluated and managed by Sivagini Ganesh, MD (Medical Director), and Bassam Yaghmour, MD.